Pharma money flows to doc­tors

The News-Times (Sunday) - - News - By Su­jata Srini­vasan This story was re­ported un­der a part­ner­ship with the Con­necti­cut Health I-Team, a non­profit news or­ga­ni­za­tion ded­i­cated to health re­port­ing. (

With physi­cians’ com­pen­sa­tion from phar­ma­ceu­ti­cal and med­i­cal de­vice com­pa­nies un­der in­creas­ing scru­tiny, pay­ments to doc­tors in Con­necti­cut for con­sul­tant work rose to $8.5 mil­lion in 2017, up from $8 mil­lion in 2016.

Pay­ments for meals, travel and gifts also in­creased slightly from $3.2 mil­lion in 2016 to $3.5 mil­lion in 2017, data from the Cen­ters for Medi­care & Med­i­caid Ser­vices show.

Of the to­tal $27.2 mil­lion in pay­ments, $4.37 mil­lion — or 16 per­cent — went to 10 doc­tors hold­ing li­censes in Con­necti­cut.

The high­est paid doc­tor was Dr. Paul Sethi, an or­tho­pe­dic sur­geon in Green­wich, who ac­cepted slightly more than $1 mil­lion in 2017 in roy­alty fees, con­sult­ing work, and other ser­vices from sev­eral com­pa­nies, in­clud­ing Arthrex Inc., and Pacira Phar­ma­ceu­ti­cals Inc., maker of Ex­parel. The drug, Ex­parel, is mar­keted as an al­ter­na­tive to opi­oid painkillers post-surgery. Sethi fre­quently takes to Twit­ter to pro­mote the use of a nono­pi­oid al­ter­na­tive and is listed on the Pacira web­site in a case study. He did not re­spond to C-HIT’s re­quest for an in­ter­view.

Dr. Robert Alpern, dean of the Yale School of Medicine, re­ceived $524,611 for his work as a di­rec­tor on the boards of Ab­bott Lab­o­ra­to­ries and Ab­bVie Inc. Alpern said he does not pro­vide paid lec­tures, does not speak for the phar­ma­ceu­ti­cal com­pa­nies, does not see pa­tients or write pre­scrip­tions, and his work on the boards is “fully dis­closed to Yale Univer­sity and Yale New Haven Hos­pi­tal.”

“I re­cuse my­self from any de­ci­sions re­lated to ei­ther of these com­pa­nies,” Alpern said.

The fi­nan­cial re­la­tion­ships be­tween phar­ma­ceu­ti­cal and med­i­cal de­vice com­pa­nies and doc­tors, as well as teach­ing hospi­tals, have been dis­closed since 2013, un­der the Af­ford­able Care Act. The law is in­tended to pro­vide trans­parency into the busi­ness con­nec­tions be­tween health care providers and the in­dus­try.

The law is also driv­ing some doc­tors — such as in­fec­tious dis­eases spe­cial­ist Dr. Roger Echols, of Eas­ton — to give up their li­cense to prac­tice medicine. “It’s why I did not revive mine last year,” he said, re­fer­ring to 2016.

Echols was paid $526,881 in 2017 for his work as a con­sul­tant pri­mar­ily for Ja­pan-head­quar­tered Shionogi & Co., best known as the maker of the choles­terol drug Crestor. Echols said he stopped see­ing pa­tients and pre­scrib­ing med­i­ca­tion years ago, when he tran­si­tioned to the phar­ma­ceu­ti­cal in­dus­try.

Even prac­tic­ing doc­tors, Echols said, are now de­clin­ing pay­ment when they meet with him to dis­cuss drug re­search. “They’ve gone so far that they won’t even al­low us to pro­vide a bagel or a cup of cof­fee at a meet­ing be­cause that has to be re­ported.”

Over­all, non-re­search pay­ments to Con­necti­cut doc­tors fell 8 per­cent from $29.7 mil­lion in 2016 to $27.2 mil­lion in 2017, the data show. Much of the de­cline oc­curred in roy­alty and li­cense fees on sales of drugs and med­i­cal de­vices, char­i­ta­ble con­tri­bu­tions, and own­er­ship or in­vest­ments in com­pa­nies.

In re­search pay­ments to Con­necti­cut doc­tors, pharma and med­i­cal de­vice com­pa­nies paid $901,196 in 2017, down from $1.1 mil­lion in 2016, ac­cord­ing to the data.

Na­tion­ally in 2017, doc­tors were paid $2.82 bil­lion by 1,525 pharma and med­i­cal de­vices com­pa­nies. Re­search pay­ments to­taled $4.66 bil­lion, the data show.

Dual role of doc­tors

The dual role of doc­tors as providers of health care to pa­tients and mar­keters for drug and med­i­cal de­vice com­pa­nies has been scru­ti­nized for sev­eral years and has been the sub­ject of ex­ten­sive re­search.

One re­port, pub­lished in a med­i­cal can­cer jour­nal that ex­am­ined sev­eral stud­ies con­cluded, “All the money and at­ten­tion drug rep­re­sen­ta­tives shower on doc­tors has its in­tended ef­fect: build­ing re­la­tion­ships with doc­tors and ul­ti­mately chang­ing how they pre­scribe.”

As­tudy pub­lished in Oc­to­ber 2017 by the U.S. Li­brary of Medicine, Na­tional In­sti­tutes of Health found that gifts from phar­ma­ceu­ti­cal com­pa­nies re­sult in higher drug costs: “More pre­scrip­tions per pa­tient, more costly pre­scrip­tions, and a higher pro­por­tion of branded pre­scrip­tions.”

“There is strong ev­i­dence that pharma pay­ments are as­so­ci­ated with higher pre­scrib­ing of the pro­moted med­i­ca­tions, and with higher costs,” said Ellen An­drews, ex­ec­u­tive di­rec­tor of the Con­necti­cut Health Pol­icy Pro­ject.

Dr. Bruce E. Strober, a pro­fes­sor of der­ma­tol­ogy at UConn Health, said, “Nearly all my col­leagues — any­body who is a spe­cial­ist in the field — do speak for drug com­pa­nies, and I am com­pen­sated for my time, yes. Unequiv­o­cally, it does not al­ter my pre­scrib­ing habits.”

Strober re­ceived $174,279 in 2017 pri­mar­ily in con­sult­ing fees from Eli Lilly and Co., Bris­tol-My­ers Squibb Co., Sanofi Gen­zyme, No­var­tis Pharma AG and Am­gen Inc., among oth­ers. In 2016, the lat­est year on record, Strober wrote 61 pre­scrip­tions for Am­gen’s En­brel amount­ing to $239,996, ac­cord­ing to a C-HIT anal­y­sis of Medi­care Part D data. The same year, Am­gen paid him $17,000.

Many doc­tors see their role as merely ed­u­cat­ing their peers, and be­ing com­pen­sated for their time and ex­per­tise.

Dr. Mark Mil­ner, an oph­thal­mol­o­gist in Hamden, re­ceived $186,125 in 2017, pri­mar­ily in con­sult­ing and speak­ing fees from pharma com­pa­nies spe­cial­iz­ing in dry eye, in­clud­ing Al­ler­gan Inc., maker of the block­buster drug Res­ta­sis.

“There is noth­ing un­eth­i­cal if I am paid for my time. I give a com­pre­hen­sive dry eye lec­ture whether I’m spon­sored by Al­ler­gan, or Shire [North] or Bausch [for­merly Valeant],” Mil­ner said.

Dr. Steven Thorn­quist, a Waterbury-based oph­thal­mol­o­gist and former pres­i­dent of the Con­necti­cut State Med­i­cal So­ci­ety, said, “The onus is on the in­di­vid­ual physi­cian to be eth­i­cal. I don’t think pa­tients should give their doc­tor the third de­gree.”

It’s a fine line.

Dr. Clau­dia Gruss, CSMS pres­i­dent, said physi­cians should de­cline a cash gift. “At the same time, there are cer­tain physi­cian ex­perts that other physi­cians look up to, and ed­u­ca­tional events al­low a very frank in­ter­change be­tween physi­cians in the field. We don’t want to de­crease pro­duc­tive col­lab­o­ra­tion.” In 2017, Gruss re­ceived $120.94 in the gen­eral cat­e­gory — the cat­e­gory in­cludes food and bev­er­age at med­i­cal con­fer­ences.

Dr. Ni­ran­jan Sankara­narayanan, a nephrol­o­gist in Bloom­field, does not ac­cept money for con­sult­ing and speak­ing en­gage­ments from pharma com­pa­nies, though he did ear­lier in his ca­reer. “I was naïve. They in­vited me to talk about a med­i­ca­tion that I was al­ready pre­scrib­ing, but af­ter one or two talks, I didn’t feel com­fort­able,” he said.

“This is a gray zone. They en­tice you with more and more, and there is no ceil­ing to this.” Sankara­narayanan said. He re­ceived $201.60 in gen­eral cat­e­gory in 2017.

Med­i­cal ethi­cists say the pub­lic must know that their physi­cians very often have com­plex in­ter­ests. “Medi­care has data­bases but more re­search needs to be done on in­cen­tives and kick­backs,” said Dr. Howard For­man, a Yale pro­fes­sor of di­ag­nos­tic ra­di­ol­ogy, eco­nom­ics and pub­lic health, who often speaks about med­i­cal ethics.

“We have to prove cause­cau­sa­tion rather than cor­re­la­tion. It’s per­ni­cious how the money flows,” For­man said.

Marie K. Shana­han / Con­necti­cut Health I-Team

Physi­cians’ com­pen­sa­tion from phar­ma­ceu­ti­cal and med­i­cal de­vice com­pa­nies to­taled $27.2 mil­lion in 2017.

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